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From the Division of Plastic Surgery, University of Wisconsin; and the Department of Plastic Surgery, Cairo University.

Received for publication October 30, 2017; accepted May 22, 2018.

Presented at the American Society of Plastic Surgeons Annual Meeting, in Chicago, Illinois, September 29, 2018; and the 57th Annual Scientific Meeting of the Midwestern Association of Plastic Surgeons, in Chicago, Illinois, April 14, 2018.

Disclosure:The authors have no financial interests to disclose in relation to the content of this article. No funding was received for this article.

A “Hot Topic Video” by Editor-in-Chief Rod J. Rohrich, M.D., accompanies this article. Go to PRSJournal.com and click on “Plastic Surgery Hot Topics” in the “Digital Media” tab to watch.

Background:

Nasal surgery is one of the most common operations performed by plastic surgeons. The link between functional nasal surgery and improvement in nasal breathing is well established, but there are other metrics that have been shown to improve as a result of anatomical correction of the nose. Current literature suggests that surgery to remove nasal mucosal contact points can reduce symptoms in chronic headache patients. The authors conducted a systematic literature review to determine the validity of this hypothesis.

Methods:

A systematic search of the literature was performed using the terms “headache,” “rhinogenic headache,” “contact point,” “migraine,” and “surgery/endoscopy.”

Results:

The authors identified 39 articles encompassing a total of 1577 patients who underwent surgery to treat mucosal contact point headaches. Septoplasty and turbinate reduction were the most commonly performed procedures, often in combination with endoscopic sinus surgery. Analysis of the combined data demonstrated improvement in the reported severity of patient symptoms, with 1289 patients (85 percent) reporting partial or complete resolution of headaches postoperatively. Average visual analogue scale scores and number of headache days in patients undergoing nasal surgery were reduced from 7.4 ± 0.9 to 2.6 ± 1.2 (p < 0.001) and 22 ± 4.3 days to 6.4 ± 4.2 days (p = 0.016), respectively. Improvement in headache symptoms was significantly associated with a positive response to preoperative anesthetic testing, and with inclusion of endoscopic sinus surgery as part of the surgery.

Conclusion:

This and Related “Classic” Articles Appear on Prsjournal.com for Journal Club Discussions.

Rhinoplasty, or nasal surgery, is one of the most commonly performed operations in the United States, with over 220,000 patients undergoing the procedure in 2016. Although statistics collected by the American Society of Plastic Surgeons demonstrate that rhinoplasty remains the third most commonly performed cosmetic procedure, a significant number of rhinoplasty operations are also performed for functional reasons. Although the term “functional rhinoplasty” refers to modification of the nasal vault for improvement in airflow through the nose, adjunctive interventions such as septoplasty and turbinate reduction are often performed simultaneously to optimize nasal breathing. Collectively, these procedures are frequently referred to as “functional nasal surgery.” The association between functional nasal surgery and improvement in nasal breathing,1–3 allergic symptoms,4,5 and obstructive sleep apnea6–8 has been thoroughly reported in the literature. However, there has also been mounting evidence to suggest that nasal surgery could be useful in the treatment of chronic headache symptoms.

In his seminal work on migraine surgery, Guyuron presented a number of various “trigger sites,” each containing peripheral structures that were hypothesized to trigger or accentuate headache symptoms.9–15 Although the bulk of his work focused on peripheral nerves and their association with chronic headaches, he and others presented evidence that a number of headaches may originate from aberrant mucosal contact points found within the nose. This led to nasal contact points, particularly those including the septum and inferior/middle turbinates, to be classified as headache trigger site 3.12

Although Guyuron popularized the idea that the nose could be a correctable source of headache symptoms, the concept of intranasal contact point headaches is not new. Mucosal contact point headaches were first introduced as early as 1942 by McAuliffe et al., who stimulated several points within the nasal mucosa to trigger referred pain to various parts of the face.16 In 2004, the International Classification of Headache Disorders listed mucosal contact point headaches as a recognizable entity, with specific criteria for diagnosis.17 In addition, the concept of surgical correction for nasal mucosal contact points has been demonstrated in the literature since 1980, when Morgenstein and Krieger delivered their report on middle turbinectomy for treatment of the “four-finger headache.”18

Since these early reports, multiple additional studies have shown that surgical correction of nasal mucosal contact points improves or cures headache symptoms. However, there have been no systematic reviews that synthesize the results of these studies. We conducted this review to demonstrate that nasal mucosal contact points may be a viable surgical target to help improve headaches in appropriately selected patients.

PATIENTS AND METHODS

We performed a systematic literature search according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (Fig. 1). An online search of the available literature was performed using PubMed, MEDLINE, EMBASE, Web of Science, and the Cochrane Library from inception to June of 2017. Searches were conducted using combinations of the terms “headache,” “rhinogenic headache,” “contact point,” “facial pain,” “migraine,” and “surgery/endoscopy.” In addition, references were also identified from bibliographies of examined articles.

Using this strategy, 624 records were initially identified and screened by the authors. Inclusion criteria included articles for which full text was available, articles written in English, studies for which surgical treatment of contact point headaches was described, articles that included the outcome of surgical intervention, and studies that included information about patient selection. Exclusion criteria included case reports, studies for which no follow-up period or selection criteria were described, review articles, and studies related to endoscopic sinus surgery alone. Based on these criteria, 39 studies were included in this analysis.9,18–55

Data were extracted regarding the number of patients, selection criteria, type of surgical interventions performed, follow-up period, and patient outcomes. Given that response to a local anesthetic was one of the criteria listed in the International Classification of Headache Disorders for diagnosis of mucosal contact point headaches,17 we also recorded this variable when available. Patient-reported outcomes were tabulated for all of the studies. After undergoing surgery, patient outcomes were divided into three categories: cure of headache symptoms, partial improvement, or no change/worsening in headache symptoms. Data were then combined to obtain the total number of patients for each category, and statistical significance was calculated using a chi-square analysis for goodness of fit. Visual analogue scale scores, if available, were also recorded and weighted averages were calculated. Similar analysis was performed for the average number of headache days preoperatively and postoperatively. Statistical comparisons for these variables were conducted using paired two-tailed t tests for comparison of means.

RESULTS

In our analysis of 39 articles, there were 1577 patients who underwent functional nasal surgery for treatment of headaches because of mucosal contact points. Range of study follow-up for the patients was 1 month to 10 years. The most common procedures that were performed were septoplasty and turbinate reduction, with all studies including at least one of these two interventions. Eighteen of the 39 studies also included endoscopic sinus surgery as part of the intervention. Although functional nasal surgery and endoscopic sinus surgery are distinctly separate operations, they are often performed in conjunction with one another. As such, endoscopic sinus surgery was included in the overall analysis when it was performed in combination with septoplasty, turbinate reduction, or traditional functional rhinoplasty.

There were two studies52,53 that were excluded from this part of the analysis as they did not report patient improvement in headache symptoms, but instead reported changes in visual analogue scale scores and number of headache days only. The remaining 37 articles that reported the primary outcome of improvement in headache symptoms encompassed a total of 1517 patients. Of these patients, 726 patients (47.9 percent) reported cure in their headaches after surgery, 563 patients (37.1 percent) reported significant improvement in either severity or frequency of headache symptoms, and 228 patients (15.0 percent) reported no change (Fig. 2) (p < 0.001). There were significantly more patients reporting either partial or complete cure than no change [1289 patients (85 percent) versus 228 patients (15 percent); p < 0.001].

Overall change in headache symptoms in patients undergoing functional nasal surgery with or without endoscopic sinus surgery. Results demonstrate 726 patients with complete relief of headache symptoms, 563 with partial improvement, and 228 with no change. Chi-square analysis for goodness of fit demonstrates significance of p < 0.001 for analysis of the entire data set and for comparison between improved patients and those with no change in headache symptoms.

Change in Average Visual Analogue Scale Scores and Number of Headache Days following Functional Nasal Surgery

Visual analogue scale scores of headache severity were identified among 446 patients in 15 articles. The weighted average visual analogue scale score was reduced from 7.4 ± 0.9 to 2.6 ± 1.2 postoperatively (Fig. 4) (p < 0.001). An additional five articles with 124 patients included an analysis of the number of headache days that patients experienced per month, both preoperatively and postoperatively. The average number of headache days was significantly reduced from 22.0 ± 4.3 days to 6.4 ± 4.2 days (Fig. 5) (p = 0.016).

Change in weighted average number of preoperative versus postoperative headache days per month in patients undergoing functional nasal surgery with or without endoscopic sinus surgery. The number of headache days was significantly reduced from 22.0 ± 4.3 days to 6.4 ± 4.2 days (p = 0.016).

Response to Surgery Based on Preoperative Lidocaine Test

We also performed a subgroup analysis based on whether patients had a positive response to a preoperative local anesthetic test, because this is a common diagnostic criterion for contact point headache.17 Of the 39 original articles, 25 studies reported using a local anesthetic test as part of their selection criteria. These 25 articles included 979 patients, with 855 patients (87.3 percent) having a positive response to the anesthetic test preoperatively. Of this subgroup, 582 (59.4 percent) had an excellent response to surgery, 285 (29.1 percent) had partial improvement, and 112 (11.4 percent) were unchanged (Fig. 6, above) (p < 0.001).

Subgroup analysis based on results of a preoperative lidocaine test. (Above) Overall response of patients who underwent lidocaine testing. Of this subgroup, 582 patients reported complete cure, 285 had partial improvement, and 112 were unchanged (p < 0.001). (Below) Response of patients who had 100 percent positive preoperative lidocaine test (red bars) versus response of those patients for whom a lidocaine test was not performed or was unreported (green bars). Comparison of these groups was statistically significant by chi-square analysis (p < 0.001).

Although these studies included the anesthetic test as part of their diagnostic criteria, not all patients were positive on this test before undergoing surgery. Therefore, we elected to separately analyze studies in which 100 percent of the patients who underwent surgery had a positive anesthetic test (Fig. 6, below). This included 17 studies totaling 694 patients. Of this subgroup, 454 patients (65.4 percent) reported total cure, 178 (25.6 percent) reported partial improvement, and 62 (8.93 percent) were unchanged (p < 0.001). Similarly, when these studies were compared with studies in which the anesthetic test was not performed or the results were unknown (12 studies, 538 patients), these results were also significant (p < 0.001). For those 12 studies in which the lidocaine test was not included as part of the selection criteria, 144 patients (26.8 percent) reported total cure, 278 (51.7 percent) reported partial improvement, and 116 (21.5 percent) reported no change.

DISCUSSION

This systematic review of 39 studies demonstrates a significant association between functional nasal surgery for treatment of nasal mucosal contact points and improvement in headache symptoms. Overall, 85 percent of patients undergoing nasal surgery with or without endoscopic sinus surgery had at least partial improvement in their headache symptoms, with 47.9 percent of patients reporting complete cure. These results were consistent across multiple metrics, with patients reporting significant improvement in average visual analogue scale scores and number of headache days postoperatively. These results suggest that the use of nasal surgery to improve headache symptoms is a viable treatment option in appropriately selected chronic headache patients. Functional nasal surgery has previously been shown to improve nasal airway breathing,1–3 allergic symptoms,4,5 and obstructive sleep apnea,6–8 and this study adds another important “function” to this commonly performed procedure.

Our review demonstrates that inferior turbinate reduction and septoplasty are the most commonly performed procedures in headache patients, likely because they address the most common nasal mucosal contact points. A number of different intranasal contact points have been implicated as potential sources of referred facial pain and headache. In their 2013 study, Bilal et al. quantified the anatomical variations in 65 patients who presented for nasal surgery for treatment of headaches.24 The most common anatomical variations included turbinate hypertrophy, nasal septal deviation, agger nasi cells, and concha bullosa. Therefore, it is unsurprising that procedures that are used to correct septal deviation and turbinate hypertrophy would be used in headache patients to address these common anatomical variants.

The overall headache cure rate of 47.9 percent and improvement rate of 37.1 percent following functional nasal surgery suggests an important relationship between intranasal anatomy and headache feedback loops. Although the proposed pathophysiology is not fully understood, a feedback loop through the trigeminal nerve distribution is thought to play a major role.56 The nasal cavity and the frontal parts of the head and sinuses are predominantly innervated by branches of the trigeminal nerve. Aberrant contact points within the nasal mucosa could lead to stimulation of the trigeminal system, leading to release of neuropeptides that cause neurogenic inflammation associated with migraine headaches, and sterile edema within the nasal mucosa.57–59 This proposed mechanism is supported by previous studies demonstrating that patients with migraine headaches report increased nasal congestion during migraine attacks, and have objective differences in measured nasal resistance during attacks.60

In addition to nasal contact points, sinus disease and possibly sinus pressure may also play an important role in headache pathophysiology. Eighteen of the studies in our systematic review included endoscopic sinus surgery as a means of addressing additional contact points in selected patients. When a subgroup analysis was performed to compare improvement in headache symptoms for patients undergoing functional nasal surgery only versus nasal surgery plus endoscopic sinus surgery, we found that approximately 85 percent of patients reported improvement in each group. However, when results for the nasal surgery–only versus nasal surgery plus endoscopic sinus surgery groups were compared, the results were significant (p = 0.007), with a higher proportion of patients reporting cure of headache symptoms with inclusion of endoscopic sinus surgery in their procedure (51.2 percent versus 44.7 percent). This finding is consistent with previous studies demonstrating improvement in sinus headaches with surgical management of sinus disease.42,44,58,61,62 Considered together, these results underscore the importance of a thorough diagnostic workup to help tailor individualized surgical treatment to each patient’s unique anatomy.

The variability in the types of procedures that can be used to treat chronic headache symptoms also highlights the need for consistent diagnostic criteria to identify patients that might benefit from surgery. According to the International Classification of Headache Disorders, the diagnosis of mucosal contact point headache must satisfy several criteria, including intermittent pain localized to the periorbital, medial canthal, or temporozygomatic regions; direct clinical or imaging evidence of mucosal contact points without acute rhinosinusitis; elimination of symptoms within 5 minutes of topical application of local anesthesia; and resolution of pain within 7 days after surgical removal of the contact point.17 The majority of the studies in our analysis confirmed the presence of mucosal contact points with computed tomographic scans and/or nasal endoscopy, indicating that these studies should be routinely conducted when identifying patients for surgical intervention. Furthermore, there is evidence that a positive anesthetic test can be predictive of surgical success. In the 2010 report by Mokbel et al., 80 percent of lidocaine test–positive patients were cured of their headaches, although 60 percent of those who were lidocaine test–negative had no change in headache symptoms.40 Similarly, Mohebbi et al.39 analyzed four different groups of patients based on computed tomography/endoscopy findings and results of a lidocaine test, with their results demonstrating significant improvement in all patients who tested positive on their anesthetic test. We attempted to control for this variable in this review by analyzing only those studies that included 100 percent positive anesthetic tests, with the results being highly significant. Subgroup analysis of patients with positive preoperative lidocaine tests demonstrated a significantly higher cure rate of 65.4 percent compared to the 26.8 percent cure rate among patients in studies that did not include a preoperative anesthetic test.

Comparison of these two groups was significant by chi-square analysis, indicating that the response of patients to surgery was more robust when they had a positive preoperative lidocaine test. Based on these results, it appears that local anesthetic testing should be a routine diagnostic criterion when considering whether a patient will benefit from functional nasal surgery for headache treatment.

Although our study demonstrated a strong correlation between nasal surgery and improvement in headache symptoms, there are several study limitations. First, the majority of the studies that were included in the analysis were retrospective chart reviews, prospective preoperative/postoperative studies, or case series, and there were only two randomized controlled trials identified in the literature.35,52 There was also no standard surgical procedure that was performed across all groups of patients. The extent and type of septoplasty or turbinate reduction that was performed was frequently not described, which could be problematic, given that we have previously demonstrated that there is wide variation among American Society of Plastic Surgeons members with regard to turbinate procedures.63,64 In addition, endoscopic sinus surgery was frequently performed in multiple studies, with variable approaches. It is therefore impossible to determine the exact effect of each individual surgical intervention on the relief of headache symptoms. In addition, patients likely had different presentations and different trials of medical treatment, which were often not described in the analysis. The type of headache symptoms that were included in each of the studies varied widely, with some studies including primary headaches such as migraines or cluster headaches, and others describing nonspecific facial pain. Finally, the outcomes that were measured in the studies were often variable or vague, with multiple studies describing “cure” or “improvement” in headache symptoms with no quantification of the severity or frequency of headache symptoms. When specific variables were reported, subjective measurements such as visual analogue scale scores were frequently used, limiting the conclusions that could be drawn from these data given the inherent bias in this type of measurement.

Finally, multiple studies have demonstrated the link between obstructed nasal breathing, obstructive sleep apnea, and migraine,60,65,66 and have also demonstrated an association between poor sleep and the development of migraine symptoms.67 Given that the primary indication for surgery is correction of nasal obstruction, it is possible that the results of our study are reflective of improvement in nasal breathing and sleep rather than a direct effect of removal of contact points on headache symptoms. Only two of the studies in our analysis included data on nasal obstruction symptoms in their postoperative study populations.33,47 In the study by Schønsted-Madsen,47 the author directly compared postoperative headache symptoms in the group of patients who had completely resolved nasal obstruction with those who had persistently obstructed breathing. This study demonstrated that 83 percent of patients with normal breathing were headache-free, whereas only 30 percent of patients with persistently obstructed breathing were free of headache symptoms. Similarly, patients in the study by Harley et al.33 demonstrated statistically significant improvements in nasal obstruction, irritability, and restlessness after undergoing surgical intervention, potentially indicating an indirect effect on sleep quality in this population. These results suggest that the improvement in headache symptoms that is demonstrated with nasal surgery is likely multifactorial in nature, and that there may be other indirect effects of these operations on sleep and breathing that have not yet been elucidated.

We have performed the first systematic review to determine whether there is an association between functional nasal surgery for treatment of mucosal contact points and improvement in headache symptoms. Although there are limitations in terms of sample size, selection criteria, and availability of randomized controlled trials, available evidence does appear to suggest that the use of functional nasal surgery is a viable treatment option in appropriately selected headache patients. Further investigation with a randomized, double-blinded, controlled study with careful selection criteria is required to identify those patients that might benefit the most from this intervention.

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David H. Song, M.D., M.B.A. is the President-elect of the American Society of Plastic Surgeons (ASPS). He is a consultant with BioMet, Emmi Solutions, LLC, a consortium-member providing senior debt for Brava, and consultant with and investor in HealthEngine.com. He receives author royalties from Elsevier. Scot Glasberg, M.D. is the President of the American Society of Plastic Surgeons (ASPS). He is a consultant with LifeCell Corp and Mentor Corp and an investor with Strathspey Crown. The authors have no sources of funding to report related to the writing or submission of this discussion.

The location and affiliation information should read as follows: Arlington Heights, Ill. From the American Society of Plastic Surgeons/Plastic Surgery Foundation.